Q No.QuestionAnswer1Have you previously been diagnosed with hayfever (seasonal allergic rhinitis) or suffered any hayfever-like symptoms such as: • Itchy, red eyes • Runny or blocked nose • Frequent sneezing You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2Have you experienced any of the following symptoms in the past? These can be a potential side-effect whilst using Fexofenadine or any other anti-histamines: • Visual disturbances • Dry mouth • Urinary retention • Chronic constipation You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3Are you allergic to any Hay fever medication? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Although some antihistamines are classed as a non-drowsy anti-histamines, please be aware that use of the medication may cause drowsiness and affect your ability to drive or operate machinery. Do you agree to check that you can tolerate use of the medication without experiencing drowsiness? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5Do you understand you should stop taking the antihistamine if your symptoms do not improve after 2 weeks of starting treatment? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6 Are you aware that there is a small chance that antihistamine tablets can cause drowsiness and impair driving? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Are you pregnant or breast feeding or intending to become pregnant or start breast feeding within the next 6 months? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8Have you been diagnosed with any of the following conditions? • Impaired kidney or liver function • Angle-closure Glaucoma • Pyloroduodenal obstruction • History of heart problems such as an irregular hearbeat, palpatations or angina You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Are you currently taking any of the following medications? • Anti-histamines, for example; Cetirizine (Zirtec), Loratidine (Clarityn), Chlorphenamine (Piriton) • Alpha-blockers such as, Tamsulosin, Terazosin, Doxazosin • Erythromicin or Ketoconazole • Medication for the treatment of Glaucoma • Anticholinergic medication such as Tolterodine, Solifenacin, Trospium You must answer this question.You must answer this question.Please write your explanation in the box below Yes No10Do you agree to the following? • You will contact your GP if you experience any side effects, if you start new medication or if your medical conditions change during treatment • The treatment is solely for your own use • You are over the age of 12 years old • You will read the patient information leaflet supplied with your medication • You have answered all the above questions accurately and truthfully. You are aware that incorrect information can be potentially hazardous to your health. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No11What is the name of your GP surgery and do you consent to us contacting them about your treatment? You must answer this question.You must answer this question.Please write your explanation in the box below Gender * Male Female Other First Name * Last Name * Date of birth * Contact Number * Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * Check to add patient. Patient Gender * Male Female Other Patient First Name * Patient Last Name * Patient Date of birth * Patient Contact Number * Patient Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * I confirm that I am over 18 and I agree to the Terms and Conditions.Term and Conditions required!Please fill all required fields
